Provider Demographics
NPI:1700103132
Name:FABELA, PAUL ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ANDREW
Last Name:FABELA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4561 HERITAGE TRACE PKWY STE 109
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-8907
Mailing Address - Country:US
Mailing Address - Phone:682-200-0035
Mailing Address - Fax:
Practice Address - Street 1:3455 LOCKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5745
Practice Address - Country:US
Practice Address - Phone:817-336-1189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-25
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP5178207R00000X
UT8134290-1205207R00000X
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3226417-01Medicaid
TX299305YNGSOtherMEDICARE - MCNT - TARRANT
TX322641702OtherMEDICAID - MCNT - TARRANT
TX299305YNGSOtherMEDICARE - MCNT - TARRANT